Molinalogo

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Claims
 Provider Dispute Resolution Request Form 

Credentialing
 CAQH Provider Data Portal
 HIV and AIDS Specialist Form 
 Provider Data Form
 Supervising Physician Provider Verification Form
 Non-Clinical Provider Form

Prior Authorizations
 Prior Authorization Code Look-up Tool
 Prior Authorization 2025 Form
 Prior Authorization 2024 Form

Additional Authorization Forms
 Applied Behavior Analysis Referral Form
 Behavioral Health Therapy Prior Authorization Form (Autism)
 Community-Based Adult Services (CBAS) Request Form
 Continuity of Care Form
 DHCS 6013A Medical Review/Prolonged Care Assessment Form
 HS-231 Certification for Special Treatment Program Services Form
 Molina ICF/DD Authorization Request Form

Referral Forms Community Supports
 Case Management Referral Form
 Community Health Worker Referral Form
 Dental Coordination Referral Form
 Doula Services Referral Form
 Enhanced Care Management (ECM) Member Referral Form - Adult
 Enhanced Care Management (ECM) Member Referral Form - Child & Youth
 Housing Specialist Referral Form
 Pregnancy Referral Form 

Community Supports 
 CS Asthma Remediation Referral Form
 CS Community Transition Services Referral Form
 CS Day Habilitation Programs Referral Form
 CS Environmental Accessibility Adaptations – Home Modification Physician Form
 CS Environmental Accessibility Adaptations – Home Modification Referral Form
 CS Housing Deposits Referral Form
 CS Housing Tenancy and Sustaining Referral Form
 CS Housing Transition Navigation Referral Form
 CS Medically Tailored Meals Referral Form - Version 3.1
 CS Personal Care and Homemaker Services Referral Form
 CS Recuperative Care Referral Form
 CS Respite Services – Home Referral Form
 CS Short-Term Post-Hospitalization Housing Referral Form
 CS Transition to Assisted Living Facilities or Residential Care Facilities Referral Form

Transportation
 Physician Certification Statement 

Pharmacy
 Medical Benefit (HCPCS/J-Code) Drug Prior Authorization Form
 Prescription Drug Prior Authorization Request Form

Other Forms and Resources
 ICE Roster Template
 Provider Information Data Form

Medi-Cal Non-Covered Services
 Member Grievance Form (English)
 Member Grievance Form (Spanish)
 Member Grievance Form (Arabic)
 Member Grievance Form (Chinese)
 Member Grievance Form (Hmong)
 Member Grievance Form (Russian)
 Member Grievance Form (Vietnamese)
 Member Grievance Form (Tagalog)
 Member Grievance Form (Farsi)
 Allowed In-Office Lab Test List, effective 5-15-2018

Health Education Forms
 Health Education Referral Form

Wellness, Prevention, and Health Management Program and Services Flyer (member handout)
 English |  Spanish |  Arabic |  Vietnamese |  Chinese |  Farsi |  Hmong |  Armenian |  Korean |  Russian |  Tagalog

Cultural & Linguistic Services Forms
Member Resources for Cultural and Linguistic Services ( English |  Spanish |  Arabic)
Provider Resources for Cultural and Linguistic Services ( English)

Smoking Cessation Resources Facility Resources
 ACOG Guidelines – Smoking Cessation During Pregnancy
 CA Quits Toolkit - A Guide to Integrate Tobacco Treatment into Health Systems
 Support Groups and Classes

Medi-Cal Pay-for-Performance Bonus Program (P4P Program)
 Enrollment Forms

Facility Resources

Inland Empire
 Inland Empire General Acute Facility Resource Guide
 Inland Empire Skilled Nursing Facility (SNF) Resource Guide
 Inland Empire Long Term Acute Care (LTAC) Facility Resource Guide

Los Angeles
 Los Angeles General Acute Facility Resource Guide
 Los Angeles Skilled Nursing Facility (SNF) Resource Guide
 Los Angeles Long Term Acute Care (LTAC) Facility Resource Guide

Sacramento
 Sacramento General Acute Facility Resource Guide
 Sacramento Skilled Nursing Facility (SNF) Resource Guide
 Sacramento Long Term Acute Care (LTAC) Facility Resource Guide

San Diego
 San Diego General Acute Facility Resource Guide
 San Diego Skilled Nursing Facility (SNF) Resource Guide
 San Diego Long Term Acute Care (LTAC) Facility Resource Guide

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